secondary pulmonary hypertension

二次性肺高血圧症

WordNet

1. not of major importance; "played a secondary role in world events"
2. the defensive football players who line up behind the linemen
3. being of second rank or importance or value; not direct or immediate; "the stone will be hauled to a secondary crusher"; "a secondary source"; "a secondary issue"; "secondary streams"
4. belonging to a lower class or rank
5. depending on or incidental to what is original or primary; "a secondary infection"

PrepTutorEJDIC

1. 『第2の』,2番目の;(…の)次の《+『to』+『名』》 / 派生的な,二次的な,あまり重要でない / 中等学校[教育]の / 二次電流の
2. 肺の;肺を冒す
3. 高血圧[症] / 過度の緊張

Wikipedia preview

出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2015/01/02 21:31:16」(JST)

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Pulmonary arterial hypertension
Classification and external resources
Micrograph showing a plexiform lesion of the lung, as seen in irreversible pulmonary hypertension. H&E stain.
ICD-10	I27.0, I27.2
ICD-9	416.0
DiseasesDB	10998
MedlinePlus	000112
eMedicine	radio/583 med/1962
Patient UK	Pulmonary hypertension
MeSH	D006976

Pulmonary hypertension (PH) is an increase of blood pressure in the pulmonary artery, pulmonary vein, or pulmonary capillaries, together known as the lung vasculature, leading to shortness of breath, dizziness, fainting, leg swelling and other symptoms. Pulmonary hypertension can be a severe disease with a markedly decreased exercise tolerance and heart failure. It was first identified by Ernst von Romberg in 1891. According to the most recent classification, it can be one of six different types (see below).

Signs and symptoms

Because symptoms may develop very gradually, patients may delay seeing a physician for years. Common symptoms are shortness of breath, fatigue, non-productive cough, angina pectoris, fainting or syncope, peripheral edema (swelling around the ankles and feet), and rarely hemoptysis (coughing up blood).

Pulmonary venous hypertension typically presents with shortness of breath while lying flat or sleeping (orthopnea or paroxysmal nocturnal dyspnea), while pulmonary arterial hypertension (PAH) typically does not.

A detailed family history is established to determine whether the disease might be familial. A history of exposure to drugs such as cocaine, methamphetamine, alcohol leading to cirrhosis, and tobacco leading to emphysema are considered significant.

A physical examination is performed to look for typical signs of pulmonary hypertension, including a split S2, and loud P2 (pulmonic valve closure sound) and (para)sternal heave indicating a hypertrophied right atrium. Signs of systemic congestion resulting from right sided heart failure are jugular venous distension, pedal edema, ascites, hepatojugular reflux, clubbing etc. Evidence of tricuspid insufficiency and pulmonic regurgitationis also sought and, if present, is consistent with the presence of pulmonary hypertension.

Causes and classification

A 1973 meeting organized by the World Health Organization was the first to attempt classification of pulmonary hypertension. A distinction was made between primary and secondary PH, and primary PH was divided in the "arterial plexiform", "veno-occlusive" and "thromboembolic" forms. A second conference in 1998 at Évian-les-Bains also addressed the causes of secondary PH (i.e. those due to other medical conditions), and in 2008, the 4th World Symposium on Pulmonary Arterial Hypertension was convened in Dana Point to modify the classification based on new understandings of disease mechanisms. The revised system developed by this group provides the current framework for understanding pulmonary hypertension. The system includes several improvements over the former 2004 Venice Classification system.

The Dana Point 2008 Updated Clinical Classification system can be summarized as follows:

• WHO Group I - Pulmonary arterial hypertension (PAH)
  • Idiopathic PAH
  • Heritable
    • BMPR2
    • ALK1, endoglin (with or without hereditary hemorrhagic telangiectasia)
    • Unknown
  • Drug- and toxin-induced
  • Associated with
    • Connective tissue disease
    • HIV infection
    • Portal hypertension
    • Congenital heart diseases
    • Schistosomiasis
    • Chronic hemolytic anemia (including sickle cell disease)
  • Persistent pulmonary hypertension of the newborn
  • WHO Group I' - Pulmonary veno-occlusive disease (PVOD) and/or pulmonary capillary hemangiomatosis (PCH)
• WHO Group II - Pulmonary hypertension owing to left heart disease
  • Systolic dysfunction
  • Diastolic dysfunction
  • Valvular heart disease
• WHO Group III - Pulmonary hypertension owing to lung disease and/or hypoxia
  • Chronic obstructive pulmonary disease
  • Interstitial lung disease
  • Other pulmonary diseases with mixed restrictive and obstructive pattern
  • Sleep-disordered breathing
  • Alveolar hypoventilation disorders
  • Chronic exposure to high altitude
  • Developmental abnormalities
• WHO Group IV - Chronic thromboembolic pulmonary hypertension (CTEPH)
• WHO Group V - Pulmonary hypertension with unclear multifactorial mechanisms
  • Hematologic diseases: myeloproliferative disease, splenectomy
  • Systemic diseases: sarcoidosis, pulmonary Langerhans cell histiocytosis: lymphangioleiomyomatosis, neurofibromatosis, vasculitis
  • Metabolic disorders: glycogen storage disease, Gaucher disease, thyroid diseases
  • Others: tumoral obstruction, fibrosing mediastinitis, chronic renal failure on dialysis

Pathogenesis

Whatever the initial cause, pulmonary arterial hypertension (WHO Group I) involves the vasoconstriction or tightening of blood vessels connected to and within the lungs. This makes it harder for the heart to pump blood through the lungs, much as it is harder to make water flow through a narrow pipe as opposed to a wide one. Over time, the affected blood vessels become both stiffer and thicker, in a process known as fibrosis. This further increases the blood pressure within the lungs and impairs their blood flow. In common with other types of pulmonary hypertension, the increased workload of the heart causes hypertrophy of the right ventricle, making the heart less able to pump blood through the lungs, ultimately causing right heart failure (a condition known as cor pulmonale). The right ventricle is normally part of a low pressure system, with pressures that are around one-sixth of those that the left ventricle has to deal with. As such, the right ventricle is much less able to cope as pressure rises, and although hypertrophy of the heart muscle helps initially, it ultimately leads to a situation where the right ventricular muscle cannot get enough oxygen to meet its needs and right heart failure follows. As the blood flowing through the lungs decreases, the left side of the heart receives less blood. This blood may also carry less oxygen than normal. Therefore it becomes harder and harder for the left side of the heart to pump to supply sufficient oxygen to the rest of the body, especially during physical activity.

Pathogenesis in pulmonary hypertension owing to left heart disease (WHO Group II) is completely different in that constriction or damage to the pulmonary blood vessels is not the issue. Instead, the left heart fails to pump blood efficiently, leading to pooling of blood in the lungs and back pressure within the pulmonary system. This causes pulmonary edema and pleural effusions.

In hypoxic pulmonary hypertension (WHO Group III), the low levels of oxygen are thought to cause vasoconstriction or tightening of pulmonary arteries. This phenomenon is called hypoxic pulmonary vasoconstriction and it is initially a protective response designed to stop too much blood flowing to areas of the lung that are damaged and do not contain oxygen. When the damage is widespread and prolonged, this hypoxia-mediated vasoconstriction occurs across a large portion of the pulmonary vascular bed and becomes a very real issue.

In chronic thromboembolic pulmonary hypertension (WHO Group IV), the blood vessels are blocked or narrowed with recurrent blood clots, and these clots can lead to release of substances that cause the blood vessels to constrict. This combination of blocked or narrowed vessels and vasoconstriction once again increases the resistance to blood flow and so the pressure within the system rises.

Molecular pathology

The molecular mechanism of pulmonary arterial hypertension (PAH) is not known yet, but it is believed that the endothelial dysfunction results in a decrease in the synthesis of endothelium-derived vasodilators such as nitric oxide and prostacyclin. Moreover, there’s a stimulation of the synthesis of vasoconstrictors such as thromboxane and vascular endothelial growth factor (VEGF). These results in a severe vasoconstriction and smooth muscle and adventitial hypertrophy characteristic of patients with PAH.

Molecular pathway of vasodilation mediated by nitric oxide

In normal conditions, the nitric oxide synthase produces nitric oxide from L-arginine in presence of oxygen. Adenylate-cyclase and gualynate-cyclase are activated in presence of nitric oxide and these enzymes produce cAMP and cGMP respectively. The cGMP is produced by a type of guanylate cyclase (which is a kind of pyrophosphate-liase cyclase): the soluble guanylate cyclase (or sGC), that catalyzes the formation of cGMP from GTP. sGC is a heterodimer made up of one α subunit and one β sub-unit in each chain. It also contains a prosthetic heme group, required for NO binding. The union of NO and sGC produces a conformational enzyme change that stimulates cGMP production.

In the vascular endothelium, cGMP activates cGMP kinase or PKG (protein kinase G), which is an enzyme that belongs to a type of serine/threonine - specific protein kinase. PKG is a dimer composed of two similar polypeptides chains that share a common molecular structure. Each subunit contains a catalytic domain and regulatory domain. GMP-kinase activates potassium channels and subsequently the inhibition of calcium channels. Thus, this process leads to a reduction of intracellular calcium and finally a vasodilation.

Phosphodiesterase type V (PDE5), which is abundant in the pulmonary tissue, is a metalohydrolase that hydrolyzes the cyclic bond of cGMP in the presence of divalent cations (Zn²⁺). Actually, Zn²⁺ union is necessary for PDE5 activity. In the N-terminal region (regulatory domain) of PDE5 there is an aminoacid sequence (residues 142-526) that joins cGMP. This sequence of PDE5 is divided in two domains; GAF-A and GAF-B; but only GAF-A has the necessary affinity to bind cGMP. This union increases the catalytic activity and it is stabilized by a close serine phosphorylation (performed by a kinase). Consequently, the concentration of cGMP decreases and the vasodilation is stopped.

Patients with PAH produce less NO and others vasodilators and produce more vasoconstrictors. Consequently, this molecular pathway doesn’t work properly and it results in a constant vasoconstriction. For this reason, NO and PDE5 inhibitors such as tadalafil or sildenafil are possible therapies. Tadalafil, for example, causes a vasodilation mediated by nitric oxide in the pulmonary endothelium.

Diagnosis

Phonocardiogram and jugular venous pulse tracing from a middle-aged man with pulmonary hypertension caused by cardiomyopathy. The jugular venous pulse tracing demonstrates a prominent a wave without a c or v wave being observed. The phonocardiograms (fourth left interspace and cardiac apex) show a murmur of tricuspid insufficiency and ventricular and atrial gallops.

Because pulmonary hypertension can be of five major types, a series of tests must be performed to distinguish pulmonary arterial hypertension from venous, hypoxic, thromboembolic, or miscellaneous varieties.

Further procedures are required to confirm the presence of pulmonary hypertension and exclude other possible diagnoses. These generally include pulmonary function tests; blood tests to exclude HIV, autoimmune diseases, and liver disease; electrocardiography (ECG); arterial blood gas measurements; X-rays of the chest (followed by high-resolution CT scanning if interstitial lung disease is suspected); and ventilation-perfusion or V/Q scanning to exclude chronic thromboembolic pulmonary hypertension. Biopsy of the lung is usually not indicated unless the pulmonary hypertension is thought to be due to an underlying interstitial lung disease; further, lung biopsies are fraught with risks of bleeding due to the high intrapulmonary blood pressure. Clinical improvement is often measured by a "six-minute walk test", i.e. the distance a patient can walk in six minutes. Stability and improvement in this measurement correlate with better survival. Blood BNP level is also being used now to follow progress of patients with pulmonary hypertension.

Pulmonary artery catheter

Diagnosis of PAH requires the presence of pulmonary hypertension. Although pulmonary arterial pressure can be estimated on the basis of echocardiography, pressure measurements with a Swan-Ganz catheter through the right side of the heart provides the most definite assessment. PAOP (pulmonary artery occlusion pressure) and PVR (pulmonary vascular resistance) cannot be measured directly with echocardiography. Therefore diagnosis of PAH requires right-sided cardiac catheterization. A Swan-Ganz catheter can also measure the cardiac output, which is far more important in measuring disease severity than the pulmonary arterial pressure.

Normal pulmonary arterial pressure in a person living at sea level has a mean value of 8–20 mm Hg (1066–2666 Pa) at rest. Pulmonary hypertension is present when mean pulmonary artery pressure exceeds 25 mm Hg (3300 Pa) at rest. Mean pulmonary artery pressure (mPAP) should not be confused with systolic pulmonary artery pressure (sPAP), which is often reported on echocardiogram reports. A systolic pressure of 40 mm Hg typically implies a mean pressure of more than 25 mm Hg. Roughly, mPAP = 0.61•sPAP + 2.

Physical examination

A physical examination is performed to look for typical signs of pulmonary hypertension. These include altered heart sounds, such as a widely split S₂ or second heart sound, a loud P₂ or pulmonic valve closure sound (part of the second heart sound), (para)sternal heave, possible S₃ or third heart sound, and pulmonary regurgitation. Other signs include an elevated jugular venous pressure, peripheral edema (swelling of the ankles and feet), ascites (abdominal swelling due to the accumulation of fluid), hepatojugular reflux, and clubbing.

Echocardiography

A meta-analysis of Doppler echocardiography for predicting right heart catheterization reported a sensitivity and specificity of 88% and 56%, respectively.

Treatment

Treatment is determined by whether the PH is arterial, venous, hypoxic, thromboembolic, or miscellaneous. Since pulmonary venous hypertension is synonymous with congestive heart failure, the treatment is to optimize left ventricular function by the use of diuretics, beta blockers, ACE inhibitors etc., or to repair/replace the mitral valve or aortic valve.

Patients with left heart failure or hypoxemic lung diseases (groups II or III pulmonary hypertension) should not routinely be treated with vasoactive agents including prostanoids, phosphodiesterase inhibitors, or endothelin antagonists, as these are approved for the different condition called pulmonary arterial hypertension. To make the distinction, doctors at a minimum will conduct cardiac catheterization of the right heart, echocardiography, chest CT, a six-minute walk test, and pulmonary function testing. Using treatments for other kinds of pulmonary hypertension in patients with these conditions can harm the patient and wastes substantial medical resources.

In PAH, lifestyle changes, digoxin, diuretics, oral anticoagulants, and oxygen therapy are considered conventional therapy, but have never been proven to be beneficial in a randomized, prospective manner.

High dose calcium channel blockers are useful in only 5% of IPAH patients who are vasoreactive by Swan-Ganz catheter. Unfortunately, calcium channel blockers have been largely misused, being prescribed to many patients with non-vasoreactive PAH, leading to excess morbidity and mortality. The criteria for vasoreactivity have changed. Only those patients whose mean pulmonary artery pressure falls by more than 10 mm Hg to less than 40 mm Hg with an unchanged or increased cardiac output when challenged with adenosine, epoprostenol, or nitric oxide are considered vasoreactive. Of these, only half of the patients are responsive to calcium channel blockers in the long term.

A number of agents have recently been introduced for primary and secondary PAH. The trials supporting the use of these agents have been relatively small, and the only measure consistently used to compare their effectivity is the "6 minute walk test". Many have no data on mortality benefit or time to progression.

Vasoactive substances

Many pathways are involved in the abnormal proliferation and contraction of the smooth muscle cells of the pulmonary arteries in patients with pulmonary arterial hypertension. Three of these pathways are important since they have been targeted with drugs — endothelin receptor antagonists, phosphodiesterase type 5 (PDE-5) inhibitors, and prostacyclin derivatives.

Because inexpensive generic drugs for this disease are not widely available, the World Health Organization does not include them in its model list of essential medicines.

Prostaglandins

Prostacyclin (prostaglandin I₂) is commonly considered the most effective treatment for PAH. Epoprostenol (synthetic prostacyclin, marketed as Flolan) is given via continuous infusion that requires a semi-permanent central venous catheter. This delivery system can cause sepsis and thrombosis. Prostacyclin is unstable, and therefore has to be kept on ice during administration. Since it has a half-life of 3 to 5 minutes, the infusion has to be continuous (24/7), and interruption can be fatal. Other prostanoids have therefore been developed. Treprostinil (Remodulin) can be given intravenously or subcutaneously, but the subcutaneous form can be very painful. An increased risk of sepsis with intravenous Remodulin has been reported by the CDC. Iloprost (Ilomedin) is also used in Europe intravenously and has a longer half life. Iloprost (marketed as Ventavis) was the only inhaled form of prostacyclin approved for use in the US and Europe, until the inhaled form of treprostinil was approved by the FDA in July 2009 and is marketed under the trade name Tyvaso. The inhaled form of administration has the advantage of selective deposition in the lungs with less systemic side effects, however coughing and throat irritation commonly occur. Oral and inhaled forms of Remodulin are under development. Beraprost is an oral prostanoid available in South Korea and Japan.

Endothelin receptor antagonists

The dual (ET_A and ET_B) endothelin receptor antagonist bosentan (marketed as Tracleer) was approved in 2001. Sitaxentan (Thelin), a selective endothelin receptor antagonist that blocks only the action of ET_A, was approved for use in Canada, Australia, and the European Union. but not in the United States. In 2010, Pfizer withdrew Thelin worldwide because of fatal liver complications. A similar drug, ambrisentan is marketed as Letairis in U.S. by Gilead Sciences. In addition, another dual/nonselective endothelin antagonist, Actelion-1, from the makers of Tracleer, will enter clinical trials in 2008.

Phosphodiesterase type 5 inhibitors

The U.S. FDA approved Sildenafil, a selective inhibitor of cGMP specific phosphodiesterase type 5 (PDE5), for the treatment of PAH in 2005. It is marketed for PAH as Revatio. In 2009, they also approved Tadalafil, another PDE5 inhibitor, marketed under the name Adcirca. PDE5 inhibitors are believed to increase pulmonary artery vasodilation, and inhibit vascular remodeling, thus lowering pulmonary arterial pressure and pulmonary vascular resistance.

Tadalafil is taken orally, as well as sildenafil, and it is rapidly absorbed (serum levels are detectable at 20 minutes). The recommended dose is 40 mg in one single dose per day and the T_1/2 (biological half-life) hovers around 17.5 hours in healthy subjects. Moreover, if we consider pharmacoeconomic implications, patients that take tadalafil would pay ⅔ of the cost of sildenafil therapy. However, there are some adverse effects of this drug such as headache, diarrhea, nausea, back pain, dyspepsia, flushing and myalgia.

Activators of soluble guanylate cyclase

Soluble guanylate cyclase (sGC) is the intracellular receptor for NO. As of April 2009, the sGC activators cinaciguat and riociguat were undergoing clinical trials for the treatment of PAH. In October 2013, riociguat (Adempas), was FDA approved for the treatment of PAH. It is the first of its class.

Surgical

Atrial septostomy is a surgical procedure that creates a communication between the right and left atria. It relieves pressure on the right side of the heart, but at the cost of lower oxygen levels in blood (hypoxia).

Lung transplantation cures pulmonary arterial hypertension, but leaves the patient with the complications of transplantation, and a post-surgical median survival of just over five years.

Pulmonary thromboendarterectomy (PTE) is a surgical procedure that is used for chronic thromboembolic pulmonary hypertension. It is the surgical removal of an organized thrombus (clot) along with the lining of the pulmonary artery; it is a very difficult, major procedure that is currently performed in a few select centers. Case series show remarkable success in most patients.

Treatment regimens for hypoxic and miscellaneous varieties of pulmonary hypertension have not been established. However, studies of several agents are currently enrolling patients. Many physicians will treat these diseases with the same medications as for PAH, until better options become available. Such treatment is called off-label use.

Monitoring

Patients are normally monitored through commonly available tests such as:

• pulse oximetry
• arterial blood gas tests
• chest X-rays
• serial ECG tests
• serial echocardiography
• spirometry or more advanced lung function studies

Prognosis

The NIH IPAH registry from the 1980s showed an untreated median survival of 2–3 years from time of diagnosis, with the cause of death usually being right ventricular failure (cor pulmonale). A recent outcome study of those patients who had started treatment with bosentan (Tracleer) showed that 89% patients were alive at 2 years. With new therapies, survival rates are increasing. For 2,635 patients enrolled in The Registry to Evaluate Early and Long-term Pulmonary Arterial Hypertension Disease Management (REVEAL Registry) from March 2006 to December 2009, 1-, 3-, 5-, and 7-year survival rates were 85%, 68%, 57%, and 49%, respectively. For patients with idiopathic/familial PAH, survival rates were 91%, 74%, 65%, and 59%.

Levels of mortality are very high in pregnant women with severe pulmonary hypertension. Pregnancy is sometimes described as contraindicated in these women.

Epidemiology

Idiopathic pulmonary arterial hypertension is a rare disease with an incidence of about 2-3 cases per million per year and a prevalence of about 15 per million. Adult females are almost three times as likely to present with IPAH than adult males. The presentation of IPAH within children is more evenly split along gender lines.

Other forms of PAH are far more common. In scleroderma the incidence has been estimated to be 6 to 60% of all patients, in rheumatoid arthritis up to 21%, in systemic lupus erythematosus 4 to 14%, in portal hypertension between 2 to 5%, in HIV about 0.5%, and in sickle cell disease ranging from 20 to 40%.

Diet pills such as Fen-Phen produced an annual incidence of 25-50 per million per year.

Pulmonary venous hypertension is exceedingly common, since it occurs in most patients symptomatic with congestive heart failure.

Up to 4% of people who suffer a pulmonary embolism go on to develop chronic thromboembolic disease including pulmonary hypertension.

Only about 1.1% of patients with COPD develop pulmonary hypertension with no other disease to explain the high pressure. Sleep apnea is usually associated with only very mild pulmonary hypertension, typically below the level of detection. On the other hand Pickwickian syndrome (obesity-hypoventilation syndrome) is very commonly associated with right heart failure due to pulmonary hypertension.

See also

• Pulmonary Hypertension Association
• Cambridge Pulmonary Hypertension Outcome Review (CAMPHOR)

References

Sources

• Rubin LJ, Badesch DB (2005). "Evaluation and management of the patient with pulmonary arterial hypertension". Ann. Intern. Med. 143 (4): 282–92. doi:10.7326/0003-4819-143-4-200508160-00009. PMID 16103472. 

External links

• The Merck Manual Home Edition: Pulmonary Hypertension
• Pulmonary Arterial Hypertension database
• Pulmonary Hypertension Association
• PH Central - the internet resource for Pulmonary Arterial Hypertension
• Facts About Primary Pulmonary Hypertension from the National Heart, Lung, and Blood Institute (NHLBI)
• Webcast: The Changing World of Pulmonary Arterial Hypertension Therapies - American College of CHEST Physicians
• GeneReviews/NCBI/NIH/UW entry on Heritable Pulmonary Arterial Hypertension
• OMIM entries on Heritable Pulmonary Arterial Hypertension

UpToDate Contents

全文を閲覧するには購読必要です。 To read the full text you will need to subscribe.

• 1. 成人における肺高血圧症の概要 overview of pulmonary hypertension in adults
• 2. 肺高血圧症の病因 pathogenesis of pulmonary hypertension
• 3. 成人における肺高血圧症の治療 treatment of pulmonary hypertension in adults
• 4. 成人における心房中隔欠損症の閉鎖適応および医療マネージメント indications for closure and medical management of atrial septal defects in adults
• 5. 成人における肺高血圧症の臨床的特徴および診断 clinical features and diagnosis of pulmonary hypertension in adults

English Journal

• Shifting chronic disease management from hospitals to primary care in Estonian health system: analysis of national panel data.

• Atun R1, Gurol-Urganci I2, Hone T3, Pell L4, Stokes J5, Habicht T6, Lukka K7, Raaper E7, Habicht J8.
• Journal of global health.J Glob Health.2016 Dec;6(2):020401. doi: 10.7189/jogh.06.020401.
• BACKGROUND: Following independence from the Soviet Union in 1991, Estonia introduced a national insurance system, consolidated the number of health care providers, and introduced family medicine centred primary health care (PHC) to strengthen the health system.METHODS: Using routinely collected heal
• PMID 27175280

• Soluble guanylate cyclase stimulator riociguat and phosphodiesterase 5 inhibitor sildenafil ameliorate pulmonary hypertension due to left heart disease in mice.

• Pradhan K1, Sydykov A1, Tian X1, Mamazhakypov A1, Neupane B1, Luitel H1, Weissmann N1, Seeger W2, Grimminger F1, Kretschmer A3, Stasch JP3, Ghofrani HA1, Schermuly RT4.
• International journal of cardiology.Int J Cardiol.2016 Aug 1;216:85-91. doi: 10.1016/j.ijcard.2016.04.098. Epub 2016 Apr 16.
• BACKGROUND: Presence of pulmonary hypertension (PH) and right ventricular dysfunction worsens prognosis in patients with chronic heart failure (CHF). Preclinical and clinical studies suggest a role for the impaired nitric oxide (NO)-soluble guanylate cyclase (sGC)-cyclic guanosine monophosphate (cGM
• PMID 27140341

• Severe non-infective systemic inflammatory response syndrome, shock, and end-organ dysfunction after zoledronic acid administration in a child.

• Trivedi S1, Al-Nofal A2, Kumar S2, Tripathi S1, Kahoud RJ1, Tebben PJ3,4.
• Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA.Osteoporos Int.2016 Jul;27(7):2379-82. doi: 10.1007/s00198-016-3528-4. Epub 2016 Feb 18.
• INTRODUCTION: Zoledronic acid is an intravenous bisphosphonate used to increase bone mineral density and reduce the risk of fractures. Its safety profile compares well with pamidronate in pediatric patients. We describe an acute, severe, life-threatening, inflammatory reaction in a child.METHODS: A
• PMID 26892041

Japanese Journal

• Effect of arginine vasopressin on systemic and pulmonary arterial pressure in a patient with pulmonary hypertension secondary to pulmonary emphysema: a case report

• JA Clinical Reports 3, 2017-01-04
• NAID 120006312183

• リウマチ性連合弁膜症に Freestyle ステントレス弁の leaflet tear による大動脈弁閉鎖不全症を合併した1手術例

• 日本心臓血管外科学会雑誌 46(2), 70-75, 2017
• NAID 130005548871

• Effects of extrathoracic mechanical ventilation on pulmonary hypertension secondary to lung disease

• Journal of anesthesia 30(4), 663-670, 2016
• NAID 40020917045

Related Links

• Pulmonary hypertension - Wikipedia, the free encyclopedia

A 1973 meeting organized by the World Health Organization was the first to attempt classification of pulmonary hypertension. A distinction was made between primary and secondary PH, and primary PH was divided in the "arterial plexiform", ...

Related Pictures

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★リンクテーブル★

リンク元	「二次性肺高血圧症」
関連記事	「secondary」「pulmonary」「hypertension」

「二次性肺高血圧症」

　　[★]

英

secondary pulmonary hypertension

関

二次性肺高血圧

「secondary」

　　[★]

• adj.

• (地位・価値・重要性などが)第2の、2番目の、(～の)次の(to)。二次的な、従位の

Postmortem examination of patients with such obstructions without a history of clinical manifestations of myocardial ischemia often shows macroscopic scars secondary to MI in regions supplied by diseased coronary arteries, with or without collateral circulation.

in the past the commonest cause of death has been venous thrombosis followed by infection secondary to severe neutropenia and hemorrhage secondary to severe thrombocytopenia.(HIM.661)(重度の好中球減少に次ぐ感染と血小板減少に次ぐ出血に続発する静脈血栓症が昔の最も一般的な死因であった)

• 副次的な(発生などが)派生的な

　 　 　 　 　 　

「pulmonary」

　　[★]

• adj.

• 肺の、肺性の

関

lung、pneumo

　

「hypertension」

　　[★] 高血圧, 高血圧症, HT